Totally transumbilical laparoscopic cholecystectomy

Trans-stomal single-port laparoscopic Hartmann's reversal is an efficacious and efficient procedure: a case-controlled study

BACKGROUND

Hartman's reversal remains challenging and is associated with a widely variable success rate. In a previous study, we reported that laparoscopy may lower the mortality and morbidity rates of the procedure. The aim of the current study was to assess the operative results of single-port laparoscopic Hartmann's reversal (SP-HR) as compared to the more standard, multi-port laparoscopic variant (MP-HR).

METHODS

We performed a retrospective, non-randomized, case-controlled study of 44 consecutive patients who had SP-HR (Group A) compared to 44 patients who had MP-HR (Group B). The study was conducted in a high-volume colorectal unit in a 1200-bed university affiliated hospital, The Poissy-Saint Germain Medical Complex, France.

RESULTS

Preoperative patients' characteristics (sex, body mass index, American Society of Anesthesiologists status, prior surgery, comorbidities, colonic disease) were comparable in both groups. The conversion rate was 13.6% and 4.5% in Group A and in Group B, respectively (p = 0.084) and consisted of placement of any additional ports. Conversion to open surgery did not occur in any patient in either group (p = 1). Mean operative time was shorter in Group A than in in Group B, (105 vs. 155 min; p = 0.0133). The mortality rate was 2.2% in Group A and 0% in Group B (p = 0.3145). The overall morbidity rate was 11.4% in Group A and 18.2% in Group B (p = 0.5344). The median length of hospital stay was significantly shorter in Group than in Group B (4.8 vs. 6.8 days; p = 0.0102).

CONCLUSIONS

The SP-HR technique was found to be safe and efficient. It compares favorably with MP-HR. Moreover, indirect cost savings could be induced by the reduction in the length of hospital stay.

Robotic versus conventional laparoscopic cholecystectomy: A comparative study of medical resource utilization and clinical outcomes

Conventional laparoscopic cholecystectomy (CLC) is currently the standard of surgical procedure for gallstone disease. Robotic cholecystectomy (RC) has revolutionized the field of minimally invasive surgery; it is safe and ergonomic, but expensive. The aim of this study is to compare the medical resource utilization and clinical outcomes between the two procedures. This study was conducted retrospectively by assessing data of the clinical outcomes and medical resource of 78 patients receiving RC and 367 patients receiving CLC. We reviewed the data of operation times, length of hospital stay, hospital charges, outpatient department visits, outpatient department service charges, and postoperative complications, which were retrieved from the health information system (HIS) database in this hospital. Patients in both groups had similar demographic and clinical features. The RC group had longer length of hospital stay (p=0.056), significantly longer operation time (p=0.035), and much more hospital charges (p=0.001). The RC group, however, experienced less postoperative complication rates (average 3.8% vs. 20.4%, p=0.001). Conversion rate was 1.9% in the CLC group versus 0% in the RC group (p=0.611). Most complications were mild, and following the Clavien-Dindo classification, there were two cases (2.5%) Grade I for the RC group; 50 cases (13.6%) Grade I and 14 cases (3.81%) Grade II for the CLC group (p<0.001 and 0.001, respectively). Procedure-related complications of Grade IIIa status were encountered in nine patients (2.45%) in the CLC group and none in the RC group (p=0.002).The RC group consumed more medical resources in the index hospitalization; however, they experienced significantly less postoperative complications.

Single-Incision Multiport/Single Port Laparoscopic Abdominal Surgery (SILAP): A Prospective Multicenter Observational Quality Study

Background

Increasing experience with minimally invasive surgery and the development of new instruments has resulted in a tendency toward reducing the number of abdominal skin incisions. Retrospective and randomized prospective studies could show the feasibility of single-incision surgery without any increased risk to the patient. However, large prospective multicenter observational datasets do not currently exist.

Objective

This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. This study focuses on external validity, clinical relevance, and the patients’ perspective. Accordingly, the single-incision multiport/single port laparoscopic abdominal surgery (SILAP) study will supplement the existing evidence, which does not currently allow evidence-based surgical decision making.

Methods

The SILAP study is an international prospective multicenter observational quality study. Mortality, morbidity, complications during surgery, complications postoperatively, patient characteristics, and technical aspects will be monitored. We expect more than 100 surgical centers to participate with 5000 patients with abdominal single-incision surgery during the study period.

Results

Funding was obtained in 2012. Enrollment began on January 01, 2013, and will be completed on December 31, 2018. As of January 2016, 2119 patients have been included, 106 German centers are registered, and 27 centers are very active (>5 patients per year).

Conclusions

This prospective multicenter observational quality study will provide a relevant dataset reflecting the feasibility and safety of single-incision surgery. An international enlargement and recruitment of centers outside of Germany is meaningful.

Trial Registration

German Clinical Trials Register: DRKS00004594; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004594 (Archived by WebCite at http://www.webcitation.org/6jK6ZVyUs)

Turkish surgeons' experiences and perception about single-incision laparoscopic surgery

OBJECTIVE

We aimed to show Turkish surgeons' current status of experience and perception about single-incision laparoscopic surgery.

MATERIAL AND METHODS

The experience and perception of general surgeons, who were members of the Turkish Surgical Association (3.5%, 116/3312), about single-incision laparoscopic surgery were analyzed according to demographic characteristics and a self-report questionnaire with the following four domains: surgeons' perception regarding the performance of single-incision laparoscopic surgery in their clinical practice; their experience of laparoscopic surgery; education, experience, and attitude for single-incision laparoscopic surgery; and the reason for performing/not performing single-incision laparoscopic surgery in their practice.

RESULTS

There were no significant factors affecting Turkish surgeons' preference of surgical approach. Although, most surgeons performing single-incision laparoscopic surgery were educated (72.2%), the dominant factor driven them to perform this surgery seemed to be personal achievement and satisfaction (57%). Most surgeons who did not perform single-incision laparoscopic surgery were not interested to do so and considered it unnecessary (62.1%). In addition, the need for special equipment and training were dominant barriers (61%).

CONCLUSION

It seems that Turkish surgeons' perception to perform single-incision laparoscopic surgery was more related to their personal achievement and satisfaction.

Comparison study of clinical outcomes between single-site robotic cholecystectomy and single incision laparoscopic cholecystectomy

BACKGROUND

Multiport laparoscopic cholecystectomy is the standard surgical procedure for symptomatic gallbladder diseases. The latest evolution is single incision laparoscopic cholecystectomy (SILC). Single-site robotic cholecystectomy (SSRC) overcomes several limitations of manual SILC. The aim of this study is to present our initial experiences in SSRC and to compare its clinical outcomes with those of SILC.

METHODS

This study retrospectively reviewed data for patients who received SSRC or SILC from February 2014 to September 2015. The following variables were analyzed: age, sex, body mass index, indications, pain scale, length of stay, and complications. The data were analyzed with Student t test or by Fisher exact test.

RESULTS

The analysis included 51 SSRC (33 women, 18 men) and 63 SILC patients (40 women, 23 men). Patients in both groups had similar demographic features and indications for surgery. The SSRC group required no conversions to conventional laparoscopy and no additional trocars, whereas the SILC group had two (3.17%) cases. Length of stay did not significantly differ between the SSRC and SILC groups (4.29 ± 0.72 vs. 4.13 ± 0.93 days, respectively; p = 0.823). However, the SSRC group had shorter operative time (71.30 ± 48.88 vs. 74.70 ± 30.16 minutes; p = 0.772), less perioperative bile spillage (9.81% vs. 19.05%; p = 0.189), and less postoperative bile leakage (0% vs. 3.17%; p = 0.501). However, the parameters mentioned above were not statistically significant, whereas pain scale scores were significantly lower in the SSRC group (2.11 ± 0.76 vs. 3.98 ± 0.84; p < 0.01).

CONCLUSIONS

Both SSRC and SILC are safe and feasible procedures for performing single incision cholecystectomy. SSRC, however, has the advantage of significantly decreased postoperative pain.

Transumbilical videolaparoscopic (single site) liver biopsy with laparoscopy equipment

INTRODUCTION

Liver diseases have a high incidence in the whole world. In order to diagnose, stage and follow these diseases it is often necessary the execution of liver biopsy. There are many possible ways to perform the procedure and the rise of transumbilical endoscopic surgery (TUES) brings to the medical practice an additional good option.

MATERIALS AND METHODS

The study is prospective, nonrandomised and cohort type. It involves 42 patients who underwent liver biopsy through TUES using conventional video laparoscopic material.

RESULTS

Among the patients 18 (42.86%) underwent isolated liver biopsy and 24 (57.14%) to liver biopsy associated with umbilical hernia repair. Within those, 27 (64.28%) were male and 15 (35.71%) female. The average body mass index (BMI) was of 27.26 kg/m(2), 10 were in the normal BMI range, 24 (57.14%) were in the overweight range, 6 (14.28%) had class I obesity and 2 (4.76%) had class II obesity. In none of the cases the procedure was converted to regular video laparoscopy, all the patients were discharged in the day after the procedure and reported a satisfactory aesthetic result.

CONCLUSIONS

The study shows that liver biopsy using TUES has applicability and good results, including in obese patients that would have a contraindication to other methods.

Do height and weight affect the feasibility of single-incision laparoscopic cholecystectomy?

BACKGROUND

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. Single-incision laparoscopic surgery has recently emerged as a less invasive potential alternative to conventional three- or four-port laparoscopy. However, the feasibility of single-incision laparoscopic cholecystectomy (SILC) remains unclear, and there are no rigorous criteria in the literature. Identifying patients at risk of failure of this new technique is essential. The aim of our study was to determine risk factors that may predict failure of the procedure.

METHODS

From May 2010 to March 2012, 110 consecutive patients underwent SILC and were reviewed retrospectively. The main feasibility criterion was the procedure failure rate, defined as addition of supplementary port(s) and prolonged (>60 min) operative time. The factors evaluated were age, gender, height, weight, body mass index, previous abdominal surgery, indication for surgery and gallbladder suspension.

RESULTS

There was conversion in 16 patients (14.5%), and the operative time exceeded 60 min for 20 patients (30.9%). Univariate analysis showed a significant independent association between additional port requirement and each of weight as a continuous value, weight ≥80 kg, BMI >26.5 kg/m(2) and height >172 cm. Univariate analysis also showed a significant independent association between prolonged operative duration (>60 min) and each of height and weight as continuous values, height >172 cm and previous abdominal surgery. In the multivariate analysis, only weight remained independently associated with additional port requirement, and height remained independently associated with prolonged operative duration.

CONCLUSION

Preoperative identification of the factors increasing the risk of conversion may assist surgeons in making decisions concerning the management of patients, including appropriate use of SILC.

Single-site laparoscopy in gynecology: preliminary study of a series of 50 cases

OBJECTIVE

to describe the initial experience of a gynecology team, at a tertiary care center, when performing single-port laparoscopic surgery.

METHODS

this is a retrospective study reviewing the medical records of 50 patients treated at the outpatient gynecology clinic of our institution between June 2012 and July 2013 who underwent single-port laparoscopic surgery. This study was approved by the institution's Ethics in Research Committee.

RESULTS

the mean age of patients is 37.8 years, ranging from 18 to 70 years, and the most frequent surgical indications were adnexal mass (72%) and chronic pelvic pain (24%). The mean operative time was 94.4 minutes with a mean hospital stay of 25.8 hours. There were no perioperative complications. We recorded two conversions to laparotomy due to technical difficulties during the procedure. All cases of conversion had pelvic adhesions. All operative complications were successfully treated and none were considered severe.

CONCLUSION

this is one of the largest case series in the literature regarding surgical treatment by single-port laparoscopy in gynecology and presents evidence on reduction of surgical morbidity and satisfactory cosmetic results. We conclude that single-port laparoscopy is a viable minimally invasive technique, and that it contributes to the construction of a new scenario in modern gynecological surgery.

Extraumbilical single-incision laparoscopic cholecystectomy with standard laparoscopic instruments

BACKGROUND AND AIM

Single-incision laparoscopic surgery is a rapidly progressing field as it combines some advantages such as cosmesis and less incisional pain. However, it also has some disadvantages such as limitation of movement and clashing of the hand instruments, which increase the complexity and technical challenges of the operation. In this study, we describe a pilot trial of single-incision laparoscopic cholecystectomy through a paramedian access site.

MATERIAL AND METHODS

A total of 25 patients underwent single-incision laparoscopic cholecystectomy with this method. Acute cases with empyema and patients with history of previous abdominal surgery were excluded. Single-incision is established on the right upper quadrant, right latero-superior of the umbilicus, so that trocar sites and projection of the gallbladder on the abdominal wall are on the same vertical line. Standard laparoscopic instruments were placed into the abdominal cavity providing triangulation. Once the laparoscope, grasper, and dissector are in place, the overall procedures are similar to the standard laparoscopic cholecystectomy.

RESULTS

Single-incision laparoscopic cholecystectomy through an extraumbilical access site was successfully completed in all 25 patients without conversion to open surgery. Additional skin incisions and trocar access were required only in two patients. The mean operative time was 39.3 min (range: 20-75 min). The mean body mass index was 27.2. Postoperative course was uneventful in all patients. The mean postoperative hospital stay was shorter than 24 h, and all patients were discharged at first day postoperatively. No postoperative complications including seroma, wound infection, and trocar-site hernia were observed at 6-month follow-up.

CONCLUSION

We described a new access site for single-incision laparoscopic cholecystectomy using standard laparoscopic instruments. We believe that this type of access site overcomes the technical difficulties of performing single-incision laparoscopic cholecystectomy, and it is a promising alternative method for the treatment of patients with symptomatic gallstone disease as a minimal invasive abdominal surgery.

The first experiences of robotic single-site cholecystectomy in Asia: a potential way to expand minimally-invasive single-site surgery?

PURPOSE

Herein, we firstly present the robotic single-site cholecystectomy (RSSC) as performed in Asia and evaluate whether it could overcome the limitations of conventional laparoscopic single-site cholecystectomy.

MATERIALS AND METHODS

From October 2013 to November 2013, RSSC for benign gallbladder (GB) disease was firstly performed consecutively in five patients. We evaluated these early experiences of RSSC and compared factors including clinicopathologic factors and operative outcomes with our initial cases of single-fulcrum laparoscopic cholecystectomy (SFLC).

RESULTS

Four female patients and one male patient underwent RSSC. Neither open conversion nor bile duct injury or bile spillage was noted during surgery. In comparisons with SFLC, patient-related factors in terms of age, sex, Body Mass Index, diagnosis, and American Society of Anesthesiologist score showed no significant differences between two groups. There were no significant differences in the operative outcomes regarding intraoperative blood loss, bile spillage during operation, postoperative pain scale values, postoperative complications, and hospital stay between the two groups (p<0.05). Actual dissection time (p=0.003) and total operation time (p=0.001) were significantly longer in RSSC than in SFLC. There were no drain insertion or open conversion cases in either group.

CONCLUSION

RSSC provides a comfortable environment and improved ergonomics to laparoscopic single-site cholecystectomy; however, this technique needs to be modified to allow for more effective intracorporeal movement. As experience and technical innovations continue, RSSC will soon be alternative procedure for well-selected benign GB disease.

Comparison of a Flexible-tip Laparoscope with a Rigid Straight Laparoscope for Single-incision Laparoscopic Cholecystectomy

This study assessed whether a flexible-tip laparoscope improves operative outcomes including operative length while performing single-incision laparoscopic cholecystectomy (SILC) compared with the use of a conventional straight laparoscope. The flexible-tip laparoscope decreased the operative time compared with the straight laparoscope. Although SILC has potential benefits, surgeons experience problems for in-line viewing through a laparoscope and from contact of instruments with the laparoscope, resulting in longer operative times and the need for additional ports. The aim of this study was to determine whether a flexible-tip laparoscope improves operative outcomes, including operative length and the rate of insertion of additional ports, while performing SILC compared with the use of a conventional rigid straight laparoscope. We reviewed data on patients for whom we performed SILC at the Department of Surgery, Kansai Medical University, for the period from November 1, 2009, to February 28, 2013. The information was assessed with respect to patient characteristics, types of laparoscope used, operative data as well as postoperative outcomes. Operating time for SILC using the flexible-tip laparoscope was significantly shorter than with the straight laparoscope (81.5 ± 23.2 vs 94.4 ± 21.1 minutes) as a result of a better view of the operating field without contact with working instruments. Although a trend was shown toward a reduced rate of the need for extra ports in the flexible-tip laparoscope group, the difference did not reach statistical significance. Using the flexible-tip laparoscope solved the problem of in-line viewing and decreased the operative time for SILC.

Advances in minimally invasive surgery in pediatric patients

Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.

Evaluation of single-port laparoscopy for peritoneal carcinomatosis assessment in advanced ovarian cancer

OBJECTIVES

Ovarian cancers are usually diagnosed at an advanced stage. The extent of the disease before surgery partly determines the ability to perform a complete cytoreduction. The peritoneal cancer index (PCI) is used to evaluate peritoneal carcinomatosis and has been validated in ovarian cancer and correlated with resectability. The aim of our study was to assess the feasibility of single-port laparoscopy (SPL) for suspicion of advanced ovarian cancer and to describe the ability to calculate the PCI score at the time of laparoscopy.

STUDY DESIGN

Between February 2011 and January 2013, 33 patients underwent SPL for suspected advanced ovarian cancer. Individual records for all patients were prospectively reviewed and analyzed. For each patient, we determined the PCI score.

RESULTS

33 patients underwent initial SPL, 85% had increased carcinological markers and 67% a radiological suspicion of peritoneal carcinomatosis. The median operative time was 90min. During SPL, 76% of patients underwent ascites evacuation; all patients had peritoneal cytology and peritoneal biopsies. Only 3 patients experienced perioperative complications. Two open conversions were recorded. Quotation of the PCI score was possible for all patients. Eighteen patients (55%) had a PCI score below 10; one had a maximal PCI score of 39. The PCI score was null for 9 patients. Non-browsing areas marked 8 procedures.

CONCLUSIONS

SPL appeared to be feasible, with satisfying immediate results and postoperative outcome, compared to conventional laparoscopy. It allowed a satisfying exploration of the abdomino-pelvic cavity and a good description of peritoneal carcinomatosis with only a few non-browsing PCI areas.

Surgical robot for single-incision laparoscopic surgery

This paper introduces a novel surgical robot for single-incision laparoscopic surgeries. The robot system includes the cone-type remote center-of-motion (RCM) mechanism and two articulated instruments having a flexible linkage-driven elbow. The RCM mechanism, which has two revolute joints and one prismatic joint, is designed to maintain a stationary point at the apex of the cone shape. By placing the stationary point on the incision area, the mechanism allows a surgical instrument to explore the abdominal area through a small incision point. The instruments have six articulated joints, including an elbow pitch joint, which make the triangulation position for the surgery possible inside of the abdominal area. The presented elbow pitch structure is similar to the slider-crank mechanism but the connecting rod is composed of a flexible leaf spring for high payload and small looseness error. We verified the payload of the robot is more than 10 N and described preliminary experiments on peg transfer and suture motion by using the proposed surgical robot.

Design and Coordination Kinematics of an Insertable Robotic Effectors Platform for Single-Port Access Surgery

Single port access surgery (SPAS) presents surgeons with added challenges that require new surgical tools and surgical assistance systems with unique capabilities. To address these challenges, we designed and constructed a new insertable robotic end-effectors platform (IREP) for SPAS. The IREP can be inserted through a Ø15 mm trocar into the abdomen and it uses 21 actuated joints for controlling two dexterous arms and a stereo-vision module. Each dexterous arm has a hybrid mechanical architecture comprised of a two-segment continuum robot, a parallelogram mechanism for improved dual-arm triangulation, and a distal wrist for improved dexterity during suturing. The IREP is unique because of the combination of continuum arms with active and passive segments with rigid parallel kinematics mechanisms. This paper presents the clinical motivation, design considerations, kinematics, statics, and mechanical design of the IREP. The kinematics of coordination between the parallelogram mechanisms and the continuum arms is presented using the pseudo-rigid-body model of the beam representing the passive segment of each snake arm. Kinematic and static simulations and preliminary experiment results are presented in support of our design choices.

Combined surgical procedures using laparoendoscopic single-site surgery approach

INTRODUCTION

As our experience with laparoendoscopic single-site (LESS) surgeries increased, we considered how it might be employed if two or more surgeries were to be combined. LESS surgeries' cosmetic advantages, decreased parietal trauma and better patient satisfaction relative to standard multiport laparoscopy have been previously reported, but its special role in combined surgeries has never been stressed. In this series, we present the advantages of LESS procedure over multiport laparoscopy in combined surgical procedures. To the best of our knowledge, this has never been reported before.

METHODS

A retrospective analysis of 27 patients was performed. The patients underwent combined LESS procedures between February 2010 and January 2012 at GEM Hospital, Coimbatore, India. All patients were of ASA grade 1 or 2. Patients with previous surgery in the umbilical region were not offered single-incision surgery.

RESULTS

We successfully performed 27 combined LESS procedures over a span of 2 years. Twenty patients were women and seven were men. Mean age was 35.94 years (range, 10-66 years). Mean BMI was 27.2. There were no major intraoperative complications. Mean blood loss was 45.7 mL (range, 0.0-120.0 mL). Mean postoperative hospital stay was 3.08 days (range, 1-5 days).

CONCLUSION

When a suitable case of multiple pathologies is encountered and LESS surgery is feasible for all of them, performing LESS surgery not only has cosmetic advantages over standard laparoscopy, but it also avoids the need for additional ports to achieve adequate visualization and access. All quadrants of the abdomen remain under reach through umbilicus.

Safety and efficacy of single-incision laparoscopic surgery for appendectomies: A meta-analysis

AIM: To compare single incision laparoscopic surgery for an appendectomy (SILS-A) with conventional laparoscopic appendectomy (C-LA) when implemented by experienced surgeons.

METHODS: Studies and relevant literature regarding the performance of single-incision laparoscopic surgery vs conventional laparoscopic surgery for appendectomy were searched for in the Cochrane Central Register of Controlled Clinical Trials, MEDLINE, EMBASE and World Health Organization international trial register. The operation time (OR time), complications, wound infection and postoperative day using SILS-A or C-LA were pooled and compared using a meta-analysis. The risk ratios and mean differences were calculated with 95%CIs to evaluate the effect of SILS-A.

RESULTS: Sixteen recent studies including 1624 patients were included in this meta-analysis. These studies demonstrated that, compared with C-LA, SILS-A has a similar OR time in adults but needs a longer OR time in children. SILS-A has similar complications, wound infection and length of the postoperative day in adults and children, and required similar doses of narcotics in children, the pooled mean different of -0.14 [95%CI: -2.73-(-2.45), P > 0.05], the pooled mean different of 11.47 (95%CI: 10.84-12.09, P < 0.001), a pooled RR of 1.15 (95%CI: 0.72-1.83, P > 0.05), a pooled RR of 1.9 (95%CI: 0.92-3.91, P > 0.05), a pooled RR of 1.01 (95%CI: 0.51-2.0, P > 0.05) a pooled RR of 1.86 (95%CI: 0.77-4.48, P > 0.05), the pooled mean different of -0.25 (95%CI: -0.50-0, P = 0.05) the pooled mean different of -0.01 (95%CI: -0.05-0.04, P > 0.05) the pooled mean different of -0.13 (95%CI: -0.49-0.23, P > 0.05) respectively.

CONCLUSION: SILS-A is a technically feasible and reliable approach with short-term results similar to those obtained with the C-LA procedure.

Single incision laparoscopic cholecystectomy: for what benefit?

BACKGROUND

A single-incision laparoscopic cholecystectomy (SILC) was developed to improve outcomes as compared with the four-port classic laparoscopic cholecystectomy (CLC). Any potential benefits associated with a SILC have been suggested by previous studies reporting few patients with different surgical techniques. The aim of this study was to describe the experience with a standardized SILC as compared with CLC.

METHODS

From June 2010 to January 2012, 40 patients underwent a SILC [median age: 47.5 years (25-92)] and operative and peri-operative data were prospectively collected. Over the same period, 37 patients underwent a CLC. A 10-point visual analogue scale (VAS) was used for qualitative data. The costs of SILC and CLC were also compared.

RESULTS

For those patients undergoing a SILC the median operating time was 70 min (24-110). There were no conversions. An additional trocar was necessary in 16 patients. Four patients developed post-operative complications. The median immediate post-operative pain score was 5 (0-10). The median quality of life and cosmetic satisfaction at the initial post-operative visit were 10 (6-10) and 10 (5-10), respectively (VAS). Although the surgical results of both groups were similar, post-operative complications were exclusively reported in the SILC group (two incisional hernias).

CONCLUSION

Standardization of SILC is possible but associated with an important rate of additional trocar placement and a disturbing rate of incisional hernias.

Single-incision versus conventional laparoscopic cholecystectomy in patients with uncomplicated gallbladder disease: a meta-analysis

BACKGROUND

Laparoscopic cholecystectomy is the gold standard treatment for cholecystectomy. Recently, single-incision laparoscopic cholecystectomy (SILC) has been suggested as an alternative technique.

METHODS

Six databases were searched and reference lists of retrieved articles were checked to identify eligible studies. Data from randomized clinical trials related to the safety and effectiveness of SILC versus conventional laparoscopic cholecystectomy (CLC) were extracted by 2 independent reviewers. Odds ratio and mean differences were calculated with 95% confidence intervals based on intention-to-treat analyses whenever possible.

RESULTS

Fifteen studies with 1113 patients met the eligibility criteria. Methodologic quality was unclear in most trails. Operating time was significantly longer in the single-incision laparoscopic surgery group compared with the CLC group (P<0.00001). Cosmesis was improved in single-incision laparoscopic patients at 1 month (P<0.00001). The pooled mean difference in pain scores at 24 hours was -0.75 in favor of the SILC technique (P=0.04). There was no significant difference in the conversion rates, adverse events, analgesia requirements, or the length of hospital stay between the 2 groups.

CONCLUSIONS

The current evidence shows that patients with uncomplicated cholelithiasis or polypoid lesions of the gallbladder who prefer a better cosmetic outcome, SILC offers a safe alternative to CLC. Further high-powered randomized trials are need to determine whether SILC truly offer any advantages, especially be focused on failure of technique, adverse events, cosmesis, and quality of life.

Laparoendoscopic single-site surgery (LESS) for treatment of benign adnexal disease: single-center experience over 3-years

STUDY OBJECTIVE

To describe the effects of laparoendoscopic single-site (LESS) surgery performed over 3 consecutive years to treat adnexal disease and to report patient perioperative outcomes.

DESIGN

Retrospective clinical study (Canadian Task Force classification III).

SETTING

Tertiary care academic medical center.

PATIENTS

Women undergoing LESS because of a benign gynecologic indication, from January 2009 through December 2011.

INTERVENTIONS

Women with benign adnexal disease ≤10 cm underwent LESS surgery through a single 1.5- to 2.0-cm umbilical incision. Intraoperative and postoperative outcomes were carefully recorded, including the need for postoperative rescue analgesia.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-five patients were enrolled. Median patient age was 49 years, and median body mass index was 23. Surgical procedures included unilateral or bilateral salpingo-oophorectomy and unilateral or bilateral cyst enucleation. Median operative time was 48 minutes. Pain control was optimal, with an average visual analog score of 4/10. Both patients and surgeons were highly satisfied with the cosmetic result, and the cosmetic visual analog score was 9/10 at discharge and at 30 days after surgery. The number of women who underwent unilateral or bilateral salpingo-oophorectomy increased progressively and significantly yearly over the study period (16 vs 23 vs 40; p = .001). Median operative time for unilateral or bilateral salpingo-oophorectomy increased significantly from 2009 to 2010 and 2011 (34 vs 45 and 44 minutes; p = .001), together with median BMI (23 vs 23 vs 25; p = .04).

CONCLUSION

LESS is a desirable surgical approach in patients with simple adnexal disease.

Single-incision laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy: meta-analysis and systematic review of randomized controlled trials

BACKGROUND

The objective of this study was to analyze systematically the randomized, controlled trials that compared single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

METHODS

The meta-analysis was conducted according to the Quality of Reporting of Meta-analysis (QUORUM) standards. The included studies were analyzed systematically using the statistical software package RevMan. The summated outcomes were expressed as the risk ratios (RR) for dichotomous variables and standardized mean differences (SMD) for continuous variables.

RESULTS

Eleven randomized trials encompassing 858 patients were retrieved from the electronic databases. In the random effects model, postoperative pain, postoperative complications, length of hospital stay, cosmesis score, conversion rate, and time to return to normal activities were statistically comparable between the two cholecystectomy techniques. SILC was associated with a longer operating time [SMD 0.71; 95 % confidence interval (CI) 0.38, 1.05; z = 4.18; p < 0.0001) and an increased requirement for additional port insertion (RR 6.54; 95 % CI 2.19, 19.57; z = 3.36; p < 0008). However, there was significant heterogeneity among the trials.

CONCLUSIONS

SILC does not offer any advantage over CLC for treating benign gallbladder disorders. CLC may be used assiduously for this purpose.

Mechanical analysis of the formation of forceps and scope for single-port laparoscopic surgery

BACKGROUND

The aim of this study is to demonstrate a shaft formation of forceps and scope which provides higher degree of freedom of motion for single-port laparoscopic surgery (SPLS). The key to smoothly performing SPLS lies in understanding the formation in which the shaft conflict is minimized. However, there have been no reported studies on conflict reduction in SPLS from a shaft formation perspective.

METHODS

When performing SPLS, 3 instruments are passed into a narrow space, only 2 patterns of shaft formation can be obtained: a formation in which the 3 instruments rotate clockwise or counterclockwise (rotation formation) or a formation in which 1 instrument passes between the other 2 (cross formation). So motion spaces of the instruments in rotation formation compared with that in cross formation were tested using engineering methods. The range of the forceps' motion was assumed to be the space covered by the forceps till collision occurred between the moving forceps and either the other fixed forceps or the fixed scope. Examination of the range of movement of the scope was conducted in the same manner. The motion space with the area on the x-y horizontal is evaluated, as viewed from the peritoneal umbilicus port entry area.

RESULTS

The motion area of each instrument in rotation formation is 1.9 to 2.6 times wider than that in cross formation.

CONCLUSIONS

Rotation formation provides high degree of freedom of motion for SPLS.

Randomized clinical study for assessment of incision characteristics and pain associated with LESS versus laparoscopic cholecystectomy

BACKGROUND

Laparoendoscopic single-site surgery (LESS) has emerged as a technique that uses a natural scar, the umbilicus, within which a multiple-entry portal is placed into a 3.0-4.0-cm single incision to perform operations. The objective of this study was to compare incision size, wound complications, and postoperative pain of LESS compared with those of laparoscopic cholecystectomy (LC).

METHODS

A prospective randomized controlled study was conducted between January and June 2011 at two university hospitals in Rio de Janeiro, Brazil. Fifty-seven patients were randomly assigned to undergo laparoscopic or LESS cholecystectomy. Skin and aponeurosis wound sizes were recorded. A 10-point visual analog scale (VAS) was used to assess pain at postoperative hours 3 and 24. Healing and wound complications were assessed at follow-up.

RESULTS

A total of 57 patients, 53 women and 4 men with a mean age of 48.7 years, were randomly assigned to undergo LESS (n = 28) or LC (n = 29). The mean length of the umbilical skin incision was 4.0 cm (range = 2.1-5.8) in LESS and 2.7 cm (1.5-5.1) in LC (p < .0001). The mean internal aponeurosis diameter was 3.5 cm (2.0-5.5) in LESS and 2.3 cm (1.2-3.5) in LC (p < .0001). The mean operative time was 60.3 min (32-128) for LESS and 51.3 min (25-120) for LC (p = 0.11). Gallbladder perforation at detachment occurred in 15.69 % of the LESS cases and in 5.88 % of the LC cases (p = 0.028). The mean VAS score for pain at hour 3 was 2.0 points (0-7) for the LESS group and 4.0 (0-10) for the LC group (p = 0.07), and at postoperative hour 24 it was 0.3 points (0-6) for LESS and 2.3 (0-10) for LC (p = 0.03). There were no significant differences in wound complications. Incisional hernias were not found in either group.

CONCLUSIONS

The LESS single-port (SP) operations demand a bigger incision than LC surgery. However, there were no differences in healing, wound infections, and hernia development. We found a tendency of less postoperative pain associated with LESS/SP than with LC.

Single-incision versus conventional laparoscopic cholecystectomy: a meta-analysis

BACKGROUND

Conventional laparoscopic cholecystectomy (CLC) is now accepted as the gold standard surgical treatment for gallbladder stone disease. Single-incision laparoscopic technology has recently been introduced into laparoscopic clinical practice in order to reduce the invasiveness of this procedure. A meta-analysis of randomized clinical trials (RCTs) was performed to compare single-incision laparoscopic cholecystectomy (SICL) and CLC.

METHODS

Medline, Embase, ISI Web of Knowledge CPCI-S and the Cochrane Library were searched and the methodological quality of the included trials was evaluated. Outcomes evaluated were adverse events, conversion rate, post-operative hospital stay, blood loss, post-operative pain, total wound length, operative time and wound satisfaction score. Results were pooled in meta-analyses as odds ratio and weighted mean differences (WMD).

RESULTS

Five RCTs on 264 patients qualified for the meta-analysis, 139 being allocated to SILC and 125 to CLC. There was no significant difference between SICL and CLC for adverse events, conversion rate, post-operative hospital stay, blood loss, post-operative pain and total wound length; however, operative time was significantly longer in SICL than in CLC (WMD 7.72 (95% confidence interval (CI): 1.38-14.07) min; P = 0.02, χ(2) P = 0.02, I(2) = 69%). Furthermore, wound satisfaction score was significantly higher in SICL than in CLC (WMD 1.40 (95% CI: 1.19-1.61) min; P < 0.00001, χ(2) P = 0.19, I(2) = 42%).

CONCLUSION

SILC may be superior to CLC in terms of cosmetic outcome, but not in operative time. Currently, SILC is a safe procedure for proper patients in experienced surgeons.

Single incision laparoscopic cholecystectomy: A review on the complications

BACKGROUND:

The aim of this study was to establish the incidence of postoperative complications after single incision laparoscopic cholecystectomy.

MATERIALS AND METHODS:

A literature search was performed using the PubMed database. Search terms included single incision laparoscopic cholecystectomy, single port cholecystectomy, minimal invasive laparoscopic cholecystectomy, nearly scarless cholecystectomy and complications.

RESULTS:

A total of 38 articles meeting the selection criteria were reviewed. A total of 1180 patients were selected to undergo single incision laparoscopic cholecystectomy. Introduction of extra ports was necessary in 4% of the patients. Conversion to open cholecystectomy was required in 0.4% of the patients. Laparoscopic cholangiography was attempted in 4% of the patients. The incidence of major complications requiring surgical intervention or ERCP with stenting was 1.7%. The mortality rate was zero.

CONCLUSION:

Although the number of complications after single incision laparoscopic cholecystectomy seems favourable, it is too early to conclude that single incision laparoscopic cholecystectomy is a safe procedure. Large randomised controlled trials will be necessary to further establish its safety.

In vivo experiments of a surgical robot with vision field control for Single Port Endoscopic Surgery

Recently, robotics systems are focused to assist in Single Port Endoscopic Surgery (SPS). However, the existing system required a manual operation of vision and viewpoint, hindering the surgical task. We proposed a surgical endoscopic robot for SPS with dynamic vision control, the endoscopic view being manipulated by a master controller. The prototype robot consists of a manipulator for vision control, and dual tool tissue manipulators (gripping: 5DOFs, cautery: 3DOFs) can be attached at the tip of sheath manipulator. In particular, this paper focuses on an in vivo experiment. We showed that vision control in the stomach and a cautery task by a cautery tool could be effectively achieved.

Laparoendoscopic single site (LESS) vs. conventional laparoscopic fundoplication for GERD: is there a difference?

BACKGROUND

This report details our experience with laparoendoscopic single site (LESS) fundoplication for GERD and provides a comparison to earlier contiguous patients undergoing conventional laparoscopic fundoplication.

METHODS

With institutional review board approval, symptoms before and after LESS fundoplications and conventional laparoscopic fundoplications were scored by patients. Outcomes after 130 consecutive LESS fundoplications were compared to 130 contiguous consecutive outcomes after conventional laparoscopic fundoplications.

RESULTS

Patients undergoing conventional laparoscopic vs. LESS fundoplication were very similar. There were no conversions to "open" operations and no notable complications with LESS fundoplication. Symptom reduction was broad and dramatic for patients undergoing LESS or conventional laparoscopic fundoplication; 96 % of patients who underwent LESS fundoplication scored their incision as ≥8 (1 = revolting to 10 = beautiful).

CONCLUSIONS

Relative to conventional laparoscopy, LESS surgery provides excellent resolution of symptoms without an apparent scar. In comparison to conventional laparoscopy, LESS fundoplication is as safe with similar symptom improvement and superior cosmesis.

Prophylactic surgery prior to extended-duration space flight: is the benefit worth the risk?

This article explores the potential benefits and defined risks associated with prophylactic surgical procedures for astronauts before extended-duration space flight. This includes, but is not limited to, appendectomy and cholecystesctomy. Furthermore, discussion of treatment during space flight, potential impact of an acute illness on a defined mission and the ethical issues surrounding this concept are debated in detail.

Patient views through the keyhole: new perspectives on single-incision vs. multiport laparoscopic cholecystectomy

OBJECTIVES

Single-incision laparoscopic cholecystectomy (SILC) may be associated with less pain, shorter hospital stay and better cosmetic results than multiport laparoscopic cholecystectomy (MLC). Advocates suggest that patients prefer SILC, although research directly addressing the question of patient preferences is limited. This study aimed to assess patient preferences using currently available evidence.

METHODS

Patients awaiting elective cholecystectomy were shown a series of postoperative images taken after SILC or MLC and asked which procedure this led them to prefer. This was repeated after patients had completed a questionnaire constructed using published objective data comparing patient-reported outcomes of SILC and MLC.

RESULTS

The study was completed by 113 consecutive patients. After their initial viewing of the images, 16% of subjects preferred MLC. Younger age, lower body mass index and female sex were associated with choosing SILC. After completing the questionnaire, 88% of patients preferred MLC (P < 0.001). Patients ranked the level of risk for complications and postoperative pain above cosmetic results in determining their choice of procedure.

CONCLUSIONS

Patients' initial preference when presented with cosmetic appearance was for SILC. When contemporary outcome data were included, the majority chose MLC. This underlines the need to fully inform patients during the consent process and indicates that patient views of SILC may differ from the views of those introducing the technology.

Early post-operative interleukin-6 and tumor necrosis factor-α levels after single-port laparoscopic varicocelectomy in children

PURPOSE

Laparoendoscopic single-site surgery has recently been described in children and regarded as an improved technology leading to less pain and better cosmetic outcome. Compared to the traditional three-port method, it is not known if the single-port method is less invasive. The aim of this study was thus to investigate the post-operative acute inflammatory response in order to evaluate surgical stress in the two surgical approaches in children.

METHODS

A prospective, single blinded, case-control study was carried out. Thirteen male patients who presented with unilateral varicocele were divided into two groups. Six children underwent single-port laparoscopic procedure, while the other seven children underwent three-port laparoscopic procedure. Pre-operative and post-operative blood samples were taken for the measurement of tumor necrosis factor-α (TNF-α) and interleukin 6 (IL-6) using ELISA. Demographics including the operation time, and complications were recorded. Data between the two groups were analyzed using unpaired t-test and a p value of <0.05 was taken as statistically significant.

RESULTS

The mean age of patients was 14.5 years (range 12-19 years). There was no significant difference between the two groups in terms of operative time, nor there was any complication recorded. The change in serum TNF-α and IL-6 concentrations pre- and post-operatively between the single-port group and three-port group was not statistically significant. Overall, patients in the two groups showed excellent satisfaction in terms of post-operative cosmesis.

CONCLUSION

Single-port laparoscopic varicocelectomy is safe, effective and produces excellent cosmesis with minimal surgical stress.

Learning curve of transumbilical single incision laparoscopic cholecystectomy (SILS): a preliminary study of 80 selected patients with benign gallbladder diseases

BACKGROUND

Transumbilical single incision laparoscopic surgery (SILS) is a new laparoscopic procedure in which only one transumbilical incision is made, demonstrated as a scarless procedure. Here we report a single-center preliminary experience of transumbilical single incision laparoscopic cholecystectomy (SILC) in the treatment of benign gallbladder diseases, defining a single surgeon's learning curve.

METHODS

A total of 80 patients underwent SILC successfully by a single experienced laparoscopic surgeon. The operation was performed following the routine LC procedure. Then the perioperative demographics were recorded and the operative time was used to define the learning curve.

RESULTS

The study group included 27 male and 53 female patients with gallstones (56 cases), cholesterol polyps (16 cases), an adenomatous polyp (3 cases), adenomyomatosis (1 case), or complex diseases (4 cases), and all consented to undergo SILC. No patient was converted to normal LC or open surgery. There were no perioperative port-related or surgical complications. The average operative time was 46.9 ± 14.6 min. The average postoperative hospital stay was 1.8 ± 1.3 days. The learning curve of the SILC procedures for this series of selected patients confirmed that SILC is a feasible, safe, and effective approach to the treatment of benign gallbladder diseases.

CONCLUSIONS

For experienced laparoscopic surgeons, SILC is an easy and safe procedure. Patients benefit from milder pain, a lower incidence of port-related complications, better cosmesis, and fast recovery. The SILC procedure may become another option for the treatment of benign gallbladder diseases for selected patients.

Single-incision laparoscopic cholecystectomy with routine intraoperative cholangiography and common bile duct exploration via the umbilical port

BACKGROUND

Laparoscopic cholecystectomy currently is the gold standard technique for gallbladder removal. The use of routine intraoperative cholangiography (IOC) is widely practiced during conventional four-port laparoscopic cholecystectomy (4PLC) to confirm biliary anatomy and allow for immediate management of unexpected choledocholithiasis. Single-incision laparoscopic surgery (SILS) offers a more aesthetic technique for gallbladder removal and has been reported by several groups. However, no series to date have included routine IOC without a separate incision. This study aimed to demonstrate the feasibility of the SILS technique for cholecystectomy with routine IOC (LCIOC) and common bile duct (CBD) exploration as needed via the umbilical port.

METHODS

A database was prospectively completed for a series of 60 consecutive patients undergoing single-incision LCIOC via the umbilical port. Details of the patients, operations, indications, outcomes, and follow-up evaluation were included.

RESULTS

Of the 60 patients included in the database, 55 (91.7%) successfully underwent single-incision laparoscopic cholecystectomy (SILC), whereas the remaining five patients required conversion to 4PLC. No patient required conversion to open cholecystectomy (OC). Of the 55 successful SILC patients, 53 (88.3%) successfully received IOCs, 48 of which were normal. The remaining five IOCs demonstrated choledocholithiasis, four of which could be managed laparoscopically without the need for conversion to either 4PLC or OC. One patient required postoperative endoscopic retrograde cholangiopancreatography (ERCP). Complications included four wound infections (7.8%), one incisional hernia (2.0%), and one bile leak (3.2%). The operating time ranged from 35 to 180 min and decreased with experience.

CONCLUSIONS

This study represents the largest series to date of single-incision laparoscopic cholecystectomies with routine IOC via the umbilical port and is the first study to demonstrate that the laparoscopic management of choledocholithiasis during SILC is feasible.

Are natural orifice transluminal endoscopic surgery and single-incision surgery viable techniques for cholecystectomy?

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) and single-incision surgery (SIS) are less invasive alternatives to traditional laparoscopic techniques. Concerns exist over the safety of these new approaches, and randomized controlled trials have yet to confirm a net benefit. If NOTES and SIS techniques are to become standard practice, then they should be shown to be safe and hold clear benefits to patients. We aim at comparing the available results by using these techniques in a standard laparoscopic operation (cholecystectomy).

METHODS

A systematic review using available databases (MEDLINE, EMBASE, and the Cochrane Controlled Trials Register) and the published English language medical literature was performed. All the archived articles were cross-referenced. Outcome data obtained from a Cochrane review of laparoscopic cholecystectomy were used as the control group. All the operations performed via a single incision were grouped under SIS, and operations in which a natural orifice (alone or as a hybrid technique) was analyzed, under NOTES group. Mortality and complications were the primary outcome measures.

RESULTS

One hundred thirty-five papers including 4703 patients (714 NOTES, 3989 SIS) were selected for analysis. Overall complication rate was 4.2% in the NOTES group versus 4.3% in the SIS group, with a distinct complication profile. No mortality was reported in either group. NOTES procedures had a longer mean operative time than SIS techniques (107 versus 79 minutes). The conversion rate between NOTES and SILS was similar (3.4% versus 3.3%, respectively).

DISCUSSION

No difference in the incidence of complications was observed with the newer techniques. Adequately powered randomized control trials are needed to clarify whether SIS/NOTES cholecystectomy has a similar length of hospital stay to traditional laparoscopic cholecystectomy. The increased occurrence of specific types of complications and their use in acute pathology needs further investigation to warrant further use in routine surgical practice.

Laparoendoscopic single-site cholecystectomy: using a gelport device

INTRODUCTION

Laparoendoscopic single-site (LESS) surgery has emerged as a viable and widely applicable minimally invasive technique. Presented here are the steps necessary to perform LESS cholecystectomy using a readily available gelport device.

METHODS

To perform LESS cholecystectomy we make a 2 cm incision through the umbilicus until the fascia is identified. The fascia is opened 2 cm and a wound protector is inserted. Through the gelport we insert a 5 mm trocar with a balloon tip for the insufflation and three 5 mm trocars as working ports. Three of the trocars are placed in the lower third in a semilunar configuration before mounting the gelport onto the wound protector. A fourth trocar can then be placed at the superior aspect of the gelport. Intra-abdominal visualization is obtained with an articulating 5 mm laparoscope.

RESULTS

At our institution 19 patients have undergone LESS cholecystectomy out of 20 attempts (5% conversion rate), with the first 15 patients undergoing a single skin incision, multifascial incision approach and the last 5 done using a gelport device and single fascial incision. One patient in the multifascial group required conversion to a dual incision laparoscopic cholecytectomy due to cystic duct bleeding. Overall, procedures averaged 81 minutes (range, 43 to 181 min), the average length of stay was <1 day (range, 0 to 2 d). To date, 1 patient developed a wound infection that responded to oral antibiosis (5% overall complication rate), and no hernias have developed with a mean follow-up of 9 months (range, 3 to 12 mo).

CONCLUSIONS

The gelport may allow for the widespread use of this exciting technology even in nonspecialized centers because of the familiarity of minimally invasive surgeons with this device. The elasticity of this device seems to facilitate the use of 4 trocars, thus, replicating the "critical view" of the structures of the triangle of Calot seen in standard multi-incision laparoscopic cholecystectomy.

Single-Incision Laparoscopic Surgery (SILS) in Biliary and Pancreatic Diseases

Laparoscopic cholecystectomy is the gold standard for gallbladder removal and the most common laparoscopic procedure worldwide. With the advent of laparoscopic surgery and its continuous development, the focus has shifted to 'scarless' surgery. In recent times, the innovative technique of single-incision laparoscopic surgery (SILS) has been applied in gallbladder removal and even more complex biliopancreatic procedures to further minimize the invasiveness of the surgery. Newer developments in laparoscopic equipments and instrumentation have helped to further evolve this field of minimally invasive surgery. Literature search was performed using the following online search engines: Google, Medline, PubMed, Cochrane, and the online Springer link library. The terms used for the search were as follows: SILS, LESS, single-incision laparoscopic surgery, single-port laparoscopic surgery, SILS cholecystectomy, and SILS pancreatic surgery. Articles that matched the search criteria were selected and extensively reviewed. Moreover, pertinent information on instrumentation and technology for SILS and LESS was obtained by accessing websites of manufacturers. Although SILS represents the search for an essentially scarless surgery, there is still not a widespread use and uniformity of this procedure. SILS is performed either by single- or multiple-port technique. In the present article, we present a review of the potential benefits, limitations, and risks of SILS in biliary and pancreatic diseases. There are many studies showing benefits in cholecystectomy. A few case reports have also emerged about its feasibility in procedures such as cystogastrostomy and limited pancreatic resection. Further research and development of this technique is needed to arrive at a tangible conclusion about the perceived benefits of SILS. Randomized studies to compare SILS with traditional laparoscopy are essential.

Single incision laparoscopic total colectomy and proctocolectomy for benign disease: initial experience

AIM

This paper presents our initial experience of single incision laparoscopic total colectomy and proctocolectomy.

METHOD

Four female patients (mean age 35.5 years; mean body mass index 24.7 kg/m(2) ) underwent total colectomy with end ileostomy (n = 2) and proctocolectomy with stapled ileum pouch-anal (n = 1) and rectal (n = 1) anastomosis with loop ileostomy, for benign disease, using a single-incision laparoscopic approach. The single port was placed at the umbilicus or the ileostomy site. Specimen extraction was through the port site.

RESULTS

Operative procedures were performed with a mean operative time of 212 min, mean blood loss of 30 ml and no intraoperative complication. No additional abdominal ports were required. A postoperative ileus (n = 1) on day three resolved spontaneously and the. mean hospital stay was 4.5 days.

CONCLUSION

Single-incision laparoscopic total colectomy or proctocolectomy is feasible for benign disease in selected patients.

Laparoendoscopic single-site lateral pancreaticojejunostomy

BACKGROUND

Chronic pancreatitis is mainly managed with drugs, but surgery is required in selected groups of patients. The Partington procedure is still the procedure of choice for patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass. The same equivalent can be achieved by laparoscopic approach. Laparoendoscopic single-site surgery gained tremendous attention in the past few years. Complex surgeries are being reported using this technique. We report in this paper the first laparoendoscopic single-site lateral pancreaticojejunostomy (LPJ) for chronic calcific pancreatitis with dilated pancreatic duct.

PATIENT AND METHOD

The procedure was performed on a 32-year-old female diagnosed to have chronic calcific pancreatitis. A single vertical 2.5-cm umbilical incision and one 10-mm and two 5-mm ports were made. The procedure was completed in 220 min without any intraoperative complication. There were no postoperative complications, and the patient was discharged on day 5 when she started taking routine diet.

CONCLUSION

This preliminary experience suggests that single-incision laparoscopic LPJ is feasible and safe when performed by an experienced laparoscopic surgeon. It has a cosmetic advantage over laparoscopic LPJ. However, it remains to be determined if this technique offers additional advantages of decreased analgesia, decreased hospital stay or cost effectiveness. Further studies are required to analyze these factors.

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy

OBJECTIVE

To compare short-term surgical outcomes and quality of life (QOL) between single-port laparoscopic cholecystectomy (SPLC) and classic 4-port laparoscopic cholecystectomy (CLC).

BACKGROUND

There is significant interest in further reducing the trauma associated with surgical procedures. Although a number of observational studies have suggested that SPLC is a feasible alternative to CLC, there is a lack of data from randomized studies validating any benefit over CLC.

METHODS

Eligible patients were randomized to receive SPLC or CLC. Operative and perioperative outcomes, including cosmesis and QOL were analyzed.

RESULTS

Forty-three patients were randomized to SPLC (n = 21) or CLC (n = 22). There were no significant differences between groups for most preoperative demographics, American Society of Anesthesiology score, gallstone characteristics, local inflammation, blood loss, or length of stay. Patients undergoing SPLC were older than those receiving CLC (57.3 years vs. 45.8 years, P < 0.05). Operative times for SPLC were greater than CLC (88.5 minutes vs. 44.8 minutes, P < 0.05). Overall and cosmetic satisfaction, QOL as determined by the SF-36 survey, postoperative complications, and post-operative pain scores between discharge and 2-week postoperative visit were not significantly different between groups. Wound infection rates were similar in both groups. The SPLC group contained 1 retained bile duct stone, 1-port site hernia, and 1 postoperative port site hemorrhage.

CONCLUSIONS

SPLC procedure time was longer and incurred more complications than CLC without significant benefits in patient satisfaction, postoperative pain and QOL. SPLC may be offered in carefully selected patients. Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another.

Single incision laparoscopic (SILS) restorative proctocolectomy with ileal pouch-anal anastomosis

BACKGROUND

Restorative proctocolectomy with ileoanal pouch is the definitive procedure in ulcerative colitis. The potential benefits afforded by a single incision laparoscopic (SILS) approach make it appropriate to consider.

METHODS

Electronic data were prospectively collected from all patients who underwent SILS restorative proctocolectomy (SILS-RPC) between June 2009 and June 2010.

RESULTS

Ten consecutive patients (4 male), with median BMI = 22 (range = 20-28 kg/m(2)) underwent SILS-LRPC over a 1-year period. Three had undergone a previous emergency laparoscopic colectomy. A single-port device (Covidien SILS™ or Olympus TriPort™) was positioned at the site of the existing or proposed temporary ileostomy (2.5-cm incision). The colon and rectum were extracted through the SILS site (n = 8) or transanally following a mucosectomy (n = 2). A 20-cm J pouch was constructed extracorporeally and returned via the ileostomy site. Pouch-anal anastomosis was performed intracorporeally (n = 8) or hand-sutured (n = 2) and a diverting loop ileostomy was created at the SILS port site. The median operation time was 185 min (range = 100-381). There were no conversions or additional ports required. Median time to full diet was 36 h (range = 4-48 h) with a median hospital stay of 3 days (range = 2-8 days). There were no 30-day readmissions. Complications included surgical emphysema with temperature and a panic attack. Nine stomas have been closed. All patients have spontaneity of defecation, with a median pouch frequency of four per day, including once at night. All are fully continent and able to defer during the day. One reported a dry ejaculate for 10 weeks.

CONCLUSION

SILS restorative proctocolectomy is safe with good early functional outcomes when performed by an experienced laparoscopic surgeon.

Bile duct injury after single incision laparoscopic cholecystectomy

This study notes that the development of single-incision laparoscopic surgery is not without risk and that obtaining the critical view in appropriately selected patients is essential for safe single-incision laparoscopic surgery.

Background:

The advancement and development of laparoscopic cholecystectomy revolutionized surgery and case management. Many procedures are routinely performed laparoscopically. Single incision laparoscopic surgery has been introduced with the hope of further reduction of scarring and possibly procedural pain. With no established technique for this procedure, the safety of single incision laparoscopic cholecystectomy has not been determined.

Methods and Results:

A 30-year-old man underwent single incision laparoscopic cholecystectomy for symptomatic cholelithiasis at an outside hospital. The operation was uneventful, and the patient was discharged home. The patient returned to the Emergency Department 4 days postoperatively, and a bile duct injury was diagnosed. A percutaneous drain was placed, and the patient was transferred to the Hepato-Pancreato-Biliary (HPB) service of a tertiary care center for definitive care. A delayed repair approach was used to allow the inflammation around the porta to decrease. Six weeks after injury, the patient underwent Roux-en-Y hepaticojejunostomy. The patient did well postoperatively.

Conclusion:

Although single incision laparoscopic surgery will play a prominent role in the future, its development and application are not without risks as demonstrated from this case. It is imperative that surgeons better define the surgical approach to achieve the critical view and select appropriate patients for single incision laparoscopic cholecystectomy.

A clinical review of single-incision laparoscopic surgery

Laparoscopic surgery is one of the most significant surgical advances of the twentieth century. Recently, the focus has been on the development of minimally invasive techniques in the form of single-incision laparoscopic surgery. The single-incision technique provides a less invasive alternative to conventional laparoscopic surgery, requiring only one incision disguised within the umbilical folds in contrast to the three to five incisions in conventional laparoscopic surgery. The availability of a number of specialised ports has aided the development of single-incision laparoscopic surgery, and led to its widespread use. The successful use of single-incision laparoscopic surgery has been reported for a number of surgical procedures, and offers several potential benefits versus conventional laparoscopic surgery, including reduced pain, reduced time to recovery and improved cosmesis. This review of international literature assesses the current status, as well as the experience, of single-incision laparoscopic surgery within general, colorectal, bariatric, metabolic, gynaecological and urological surgery. The challenges faced with single-incision laparoscopic surgery are discussed, as well as the clinical studies that are required in order to establish single-incision surgery as a significant improvement to conventional laparoscopic surgery in terms of reduced pain and improved cosmesis.

[Single port transumbilical cholecystectomy [SILS] -- 30 non-selected cases]

Single port laparoscopic surgery became popular all over the world, and cholecystectomy represents the most frequent intervention with this technique. We compared transumbilical single port laparoscopic cholecystectomies (SILS) to conventional three-port laparoscopic cholecystectomies (LC), which were performed by the same surgeon between 2008-2010. As regards SILS cases, they represent a non-selected series. Transabdominal sutures were not applied in any of those, but one additional 5 mm port was inserted in two SILS cases. Only straight instruments were used in all but two SILS cholecystectomies. Mean age of patients was lower in the SILS group, however male:female ratio and BMI were similar. While none of the procedures were converted in the SILS group, one needed to be done so in the LC patients. One of the SILS patients underwent a transumbilical laparoscopic wash-out for an intrabdominal haematoma, which developed due to non-surgical reasons. Mean operative time and postoperative hospitalisation was 75.9 ± 25 minutes and two days in the SILS group, while 55.7 ± 17 minutes and 2.8 days in the LC group, respectively. We concluded that transumbilical single port cholecystectomy can be performed safely by using conventional straight instruments. We could not identify any publication about non-selected SILS cholecystectomy series in the English language literature.

Single-port liver cyst fenestration combined with single-port laparoscopic cholecystectomy using completely reusable instruments

We report a technique for umbilical single-port liver cyst fenestration combined with cholecystectomy using only standard and reusable laparoscopic instruments. The single-port technique seems to be a safe and simple technique for liver cyst fenestration with cholecystectomy and is cosmetically superior to standard laparoscopic procedures.